RU2729507C1 - Method for minimally invasive intrasinusous elimination of defects and deformations of maxillary sinus upper wall and enophthalmos - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medicine, namely to maxillofacial surgery. First stage involves spiral computed tomography of upper jaw and orbit. Results of the tomography are used to determine the shape and size of an orbital floor defect. Enophthalmos value and a degree of peripheral tissue prolapse into the maxillary sinus, a maxillary sinus size and shape are assessed. According to the results of spiral computed tomography, a cylindrical titanium rod is made, which is equal to the vertical size of the maxillary sinus, one end of which is smooth without thread, tapered at angle of 45 degrees, and other end has external thread, on which nut is screwed. Mucous-gingival line is incised mucous membrane with periosteum from 2 to 5 teeth, muco-periosteal flap is shifted upwards, skeleton of maxillary sinus front wall. Milling hole is formed in an anterior wall with size of 15 by 10 mm, a Schneiderian membrane is detached from the anterior, upper and lateral walls of the maxillary sinus. Endoscopic support is used to visualize the upper wall of the maxillary sinus, assessing the defect value of the upper wall of the maxillary sinus, comparing with the data obtained by tomography. It involves reposition and / or removal of bone fragments. Then, perforated hole 4 mm in diameter is formed in the middle one-third of a malaralveolar ridge, a biodegradable plate of polylactic acid with thickness of 1 mm is formed, in size larger than defect by 2 mm along the perimeter, and laid on the defect. Inserting into the perforation hole an end of a cylindrical titanium rod with diameter of 3 mm, which is bevelled at angle of 45 degrees, the biodegradable plate is pressed and fixed with a cylindrical titanium rod, rod is fixed with nut inside bay of malaralveolar ridge. Then Schneiderian membrane is returned into place, wound is closed, sutures are removed on 7th day. In the second stage, 3 months later, after resorption of the biodegradable plate, X-ray control is performed, then a cylindrical titanium rod is removed under local anesthesia.EFFECT: method enables performing the surgical intervention with minimal traumaticity, avoiding incisions on the face, eliminating bone defects of the upper wall of the maxillary sinus and enophthalmos, makes it possible to distribute more uniformly load over a greater bone area of the upper wall of the maxillary sinus, to enable removal of the structure after the treatment by a non-invasive method.1 cl, 7 dwg, 1 ex

Description

The invention relates to medicine, namely to maxillofacial surgery, and can be used in ophthalmology, otorhinolaryngology.

A known method for the dynamic elimination of enophthalmos. SUBSTANCE: method includes introduction through intra-sinus access of a device containing a T-shaped titanium miniplate having an oval hole in the middle of the vertical part and two holes for screws at the ends of the horizontal part. To the end of the vertical part of the T-shaped titanium miniplate, an L-shaped titanium miniplate is connected by means of the first hinge-like connection in the loop-like manner with a long part, having holes for a thread for attaching a silicone block in the long part. In the place of transition of the horizontal part of the T-shaped titanium miniplate to the vertical one, from the inner side, a straight titanium miniplate is connected by means of a second hinge-like connection, the opposite end of which rests against the bend of the L-shaped titanium miniplate. The straight titanium miniplate has a threaded hole located in the middle of the projection onto it of the oval hole of the vertical part of the T-shaped titanium miniplate. The device is inserted through the intra-sinus approach, the horizontal part of the T-shaped titanium miniplate is attached to the anterior wall of the maxillary sinus using screws. Additionally, a milling hole is made on the antero-outer wall of the maxillary sinus at the level of the oval hole of the vertical part of the T-shaped titanium miniplate, a screw 15-20 mm long is inserted through the oval hole in the vertical part of the T-shaped titanium miniplate and a threaded hole in the straight titanium miniplate. When screwing in a screw 15-20 mm long, the straight titanium miniplate approaches the vertical part of the T-shaped titanium miniplate, due to its rotation in the second hinge joint, while the end of the straight titanium miniplate, resting on the bend of the L-shaped titanium miniplate, brings the latter into movement by turning it in the first articulated joint, lifting the long part with the silicone block and the eyeball. In the postoperative period, when a displacement of the pupillary line is detected, an incision is made in the area of the screw head with a length of 15-20 mm, it is screwed in, thereby correcting the position of the L-shaped titanium miniplate with a silicone block and the eyeball. The method allows to correct the position of the eyeball both during surgery and in the postoperative period; achieve stable and strong fixation of bone fragments; prevents trauma to the roots of the teeth and infraorbital nerve (RF Patent No. 2581261 from 20.04.2016, bull. No. 11). The disadvantages of this method include:

1) the complexity of the design;

2) a large volume of metal elements located in the maxillary sinus;

3) damage to the Schneider membrane and the mucous membrane of the maxillary sinus;

4) the need for a second operation to remove the structure.

The closest in technical essence is the method of correction of enophthalmos. The mucous membrane of the hard palate is excised, the palatine process is skeletonized, and a bony canal is formed from the crest of the alveolar process of the upper jaw to the bottom of the maxillary sinus with its perforation. A metal structure is introduced, consisting of a first hollow cylindrical tube, a screw and a second hollow cylindrical tube with drop-down elements in the form of petals. The first cylindrical hollow tube with external and internal threads is screwed into the formed channel, having a socket for the screwing tool at the lower end. Then the second cylindrical tube with the opening elements in the form of petals at the upper end is placed with the lower end on the upper smooth part of the screw until it stops on the support platform formed at the place of increase in the screw diameter during the transition from the smooth section to the section with a thread corresponding to the internal thread of the first cylindrical hollow tube ... At the bottom end of the screw there is a hexagonal protrusion for the screwing tool. The expandable elements are clamped together and the resulting assembly is placed in the first tube. The clamp is removed and the screw is screwed in, while the expanding elements straighten the petals when leaving the first tube, with further screwing in the screw, the opening element is brought to the upper wall of the sinus and acts on it, eliminating the deformation of the lower wall of the orbit. A cap screw is inserted into the bottom of the first tube. The flaps are placed in place and sutured (RF Patent No. 2616124 dated 12.04.17)

The disadvantages of this method are:

1) Technical difficulties in installing the structure

2) Damage to the Schneider membrane

3) The need for a second stage of surgery to remove the structure.

The purpose of the invention is to create a minimally invasive method for intra-sinus elimination of defects in the upper wall of the maxillary sinus and enophthalmos.

The purpose is achieved by the method of minimally invasive intra-sinus elimination of defects and deformities of the upper wall of the maxillary sinus and enophthalmos. The first stage is a spiral computed tomography of the upper jaw and orbit. According to the results of tomography, the shape and size of the defect in the bottom of the orbit is determined. The size of enophthalmos and the degree of prolapse of the periorbital tissues in the maxillary sinus, the size and shape of the maxillary sinus are assessed. According to the results of spiral computed tomography, a cylindrical titanium rod is made, equal to the vertical size of the maxillary sinus, one end of which is smooth without thread, beveled at an angle of 45 degrees, and the other end has an external thread, onto which a nut is screwed. Along the mucous-gingival line, an incision is made in the mucous membrane with the periosteum from 2 to 5 teeth, the mucoperiosteal flap is displaced upward, the anterior wall of the maxillary sinus is skeletonized. A hole in the anterior wall of 15 by 10 mm is formed with a cutter, the Schneider's membrane is separated from the anterior, superior and lateral walls of the maxillary sinus with a rasp. With endoscopic support, the upper wall of the maxillary sinus is visualized, the size of the defect of the upper wall of the maxillary sinus is estimated, comparing with the data obtained by tomography. Bone fragments are repositioned and / or removed. Next, a perforation with a diameter of 4 mm is formed in the middle third of the zygomatic alveolar ridge, a biodegradable plate of polylactic acid with a thickness of 1 mm is formed, the size is larger than the defect by 2 mm around the perimeter, and placed on the defect. The end of a cylindrical titanium rod with a diameter of 3 mm is introduced into the perforation hole, beveled at an angle of 45 degrees, the biodegradable plate is pressed and fixed with a cylindrical titanium rod, the rod is fixed with a nut inside the bay of the zygomatic alveolar ridge. Then Schneider's membrane is returned to its place, the wound is sutured, the sutures are removed on the 7th day. At the second stage, after 3 months, after the resorption of the biodegradable plate, X-ray control is performed, then the cylindrical titanium rod is removed under local anesthesia.

The novelty of the invention:

1. Lack of constructions in the late postoperative period

2. Application of biodegradable material (form a biodegradable plate of polylactic acid 1 mm thick, larger than the defect by 2 mm around the perimeter and placed on the defect)

3. Preservation of the integrity of the Schneider membrane

4. According to the results of the CT scan, a cylindrical titanium rod is made in size congruent to the vertical size of the maxillary sinus, one end of which is smooth without thread, beveled at an angle of 45 degrees, and the other end has an external thread on which a nut is screwed.

5. The biodegradable plate is pressed and fixed with a cylindrical titanium rod. The rod is fixed with a nut inside the bay of the zygomatic alveolar ridge.

6. After 3 months, after the resorption of the biodegradable plate, X-ray control is performed, then the cylindrical titanium rod is removed under local anesthesia.

The combination of essential features of the invention allows you to obtain a new technical result:

1) to carry out surgery with minimal trauma,

2) avoid facial incisions,

3) eliminate bone defects of the upper wall of the maxillary sinus and enophthalmos,

4) allows you to distribute the load more evenly over a larger area of the bone of the upper wall of the maxillary sinus,

5) to be able to remove the structure after treatment in a non-invasive way.

The invention is illustrated by the drawings shown in FIG. 1-7.

FIG. 1 - cylindrical titanium rod.

FIG. 2 - shows the assembled installed structure.

FIG. 3 - view of the patient upon admission to the hospital.

FIG. 4 - CT scan of the middle zone of the face before the operation.

FIG. 5 is a view of the patient after the end of treatment.

FIG. 6 - view of the patient after 3 months.

FIG. 7 - repeated SKT examination after 3 months.

The design is a cylindrical titanium rod 1, one end of which is smooth without thread, beveled at an angle of 45 degrees, and the other end has an external thread 2, onto which a nut 3 is screwed, fixing the rod inside the bay of the zygomatic alveolar ridge (Fig. 1, 2).

The method is carried out as follows.

The first step is to perform spiral computed tomography (SCT) of the upper jaw and orbit. According to the results of tomography, the shape and size of the defect in the bottom of the orbit is determined. Evaluate the size of enophthalmos and the degree of prolapse of the periocular tissues into the maxillary sinus, the size and shape of the maxillary sinus. According to the results of CT scan, a cylindrical titanium rod is made in size congruent to the vertical size of the maxillary sinus (Fig. 1, Fig. 4).

Along the mucous-gingival line, an incision is made in the mucous membrane with the periosteum from 2 to 5 teeth. The muco-periosteal flap is displaced upward, the anterior wall of the maxillary sinus is skeletonized, a hole is formed in the anterior wall of 15 x 10 mm with a cutter. Using a rasp, the Schneider's membrane is removed from the anterior, superior and lateral walls of the maxillary sinus. With endoscopic support, the upper wall of the maxillary sinus is visualized. The size of the defect of the upper wall of the maxillary sinus is assessed, comparing with the data obtained by tomography, reduction and / or removal of bone fragments is carried out. A 4 mm perforation is formed in the middle third of the zygomatic alveolar ridge. Next, a biodegradable plate 4 of polylactic acid (PLA) with a thickness of 1 mm is formed, the size is larger than the defect by 2 mm around the perimeter and placed on the defect. The end of a cylindrical titanium rod 1 with a diameter of 3 mm is introduced into the perforation hole, beveled at an angle of 45 degrees. The biodegradable polylactic acid plate 4 is pressed and tightly fixed with a cylindrical titanium rod 1, the rod is fixed with a nut 3 inside the bay of the zygomatic alveolar ridge. Next, the Schneider membrane is returned to its place. The wound is sutured. The stitches are removed on the 7th day. The second stage after 3 months is the time of resorption of the biodegradable plate, X-ray control is performed, then the cylindrical titanium rod 1 is removed under local anesthesia.

Clinical example.

Patient B., 40 years old, after examination was diagnosed with an explosive fracture of the lower wall of the right orbit (Fig. 3).

On external examination, there is a moderate left-sided hyperphthalmos, with a dislocation of the eyeball within 2 mm, limitation of the mobility of the eyeball downward, due to the infringement of the lower rectus muscle in the fracture gap. The patient's complaints were dominated by numbness of the skin of the infraorbital region on the left, of the teeth of the upper jaw within the incisors, canine and first premolar, and double vision when looking up.

The first step was performed by spiral computed tomography (SCT). According to the SCT data, the lower wall of the orbit is displaced into the cavity of the maxillary sinus by 7 mm. The left optic nerve in the distal part is displaced downward by 2.5 mm. The anteroposterior size of the defect is 19 mm, the width in the frontal plane is 14 mm (Fig. 4). According to the results of CT scan, a cylindrical titanium rod was made in size congruent to the vertical size of the maxillary sinus.

During the operation, a Caldwell-Luke incision was made in the region of the 22-26 teeth of the upper jaw on the left. A mucoperiosteal flap was mobilized. A hole 1.5 cm in diameter was imposed on the antero-outer wall of the maxillary sinus. Detached Schneider's membrane from the upper-lateral wall of the maxillary sinus. With endoscopic support, the upper wall of the maxillary sinus was visualized. Its deformation was determined in the anterior and middle sections with a diameter of up to 25 by 15 mm. An osteotomy of the deformed portion of the bone of the upper wall of the maxillary sinus was performed, the fragment was moved to the anatomical position. Formed a perforation with a diameter of 4 mm in the middle third of the zygomatic alveolar ridge.

A plate was cut out of a biodegradable material - polylactic acid (PLA), 1 mm thick, 27 by 17 mm, laid on the defect. Through the perforation in the middle third of the zygomatic alveolar ridge on the left, the rod is brought to the plate and fixed inside the bay of the zygomatic alveolar ridge with a nut. Further, the Schneider's membrane was returned to its place, the soft tissues were sutured. In the postoperative period, the patient was prescribed antibacterial and symptomatic therapy. The stitches were removed on the 7th day. When observing the patient, photographic control was carried out after the end of the hospital stay and 3 months after the operation (Fig. 5, 6), the CT scan was repeated (Fig. 7).

After 3 months, after X-ray control under local anesthesia, a titanium rod was removed from the maxillary sinus.

Moderate hyperphthalmos is observed due to edema of bulbar tissue. There is no limitation of the mobility of the eyeball (since the lower rectus muscle of the eye is released). He has no complaints about double vision. Numbness persists in the area of the teeth of the upper jaw in segment 21-24.

Claims (1)

Method for minimally invasive intra-sinus elimination of defects and deformities of the upper wall of the maxillary sinus and enophthalmos, including spiral computed tomography, access and introduction of a metal structure, characterized in that at the first stage, according to the results of spiral computed tomography, a cylindrical titanium rod is made according to the size of the congruent maxillary vertical size one end of which is smooth without thread, beveled at an angle of 45 degrees, and the other end has an external thread, onto which a nut is screwed; along the mucous-gingival line, an incision is made in the mucous membrane with the periosteum from 2 to 5 teeth, the mucoperiosteal flap is displaced upward, the anterior wall of the maxillary sinus is skeletonized, a hole is formed in the anterior wall 15 by 10 mm in size with a cutter, the Schneider's membrane is cut off from the anterior, upper and the lateral wall of the maxillary sinus, with endoscopic support, the upper wall of the maxillary sinus is visualized, the size of the defect of the upper wall of the maxillary sinus is estimated, comparing with the data obtained by tomography, reduction and / or removal of bone fragments is performed, then a perforation with a diameter of 4 mm is formed in the middle third zygomatic alveolar ridge, form a biodegradable plate of polylactic acid 1 mm thick, larger than the defect by 2 mm around the perimeter, and put on the defect, insert the end of a cylindrical titanium rod with a diameter of 3 mm into the perforation hole, beveled at an angle of 45 degrees, biodegr The adhered plate is pressed and fixed with a cylindrical titanium rod, the rod is fixed with a nut inside the bay of the zygomatic alveolar ridge, then the Schneider membrane is returned to its place, the wound is sutured, the sutures are removed on the 7th day; the second stage, after 3 months, after the resorption of the biodegradable plate, an X-ray control is performed, then a cylindrical titanium rod is removed under local anesthesia.

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